‘Dear Physician’: Updates to DME Documentation Requirements Hold You Accountable

CMS documentation guidelines add orthotists, prosthetists to medical record

The Centers for Medicare & Medicaid Services (CMS) recently updated the durable medical equipment (DME) documentation guidelines. And the revisions are significant, as you’ll discover in the latest CMS documentation guidelines webinar presented by coding director Lynn Anderanin.

Arguably one of the biggest changes involves four DME Medicare Administrative Contractors (MACs) and a revised “Dear Physician” letter regarding DME general documentation requirements. Read on to find out a bit more about what you can expect in 2019.

Orthotists & Prosthetists: Your Notes Now Count (Again)

Although “medical necessity” is a term that’s surely been hammered into your consciousness by now, it’s also a term that can be somewhat vague. Especially when it comes to whose notes count toward proving medical necessity: Exactly whose notes count?

The enactment in February 2018—and backing by CMS—of Section 50402 made things a little clearer: Now the clinical notes of orthotists and prosthetists (O&Ps) demonstrate medical necessity for DMEs in the medical record.

Refresher: Section 50402 is a one-sentence amendment tacked on to Section 1834(h) of the Social Security Act. The exact phrasing of the amendment is: “(5) DOCUMENTATION CREATED BY ORTHOTISTS AND PROSTHETISTS. – For purposes of determining the reasonableness and medical necessity of orthotics and prosthetics, documentation created by an orthotist or prosthetist shall be considered part of the individual’s medical record to support documentation created by eligible professionals described in section 1848(k)(3)(B).”

The amendment is key because it reverses a 2011 “Dear Physician” letter that stated such notes did not count. The main benefit of this new clarity is (hopefully) to reduce the backlog of claims under CMS audit, since O&P practitioners will now be able to determine just how medically necessary certain orthotic and prosthetic devices are when submitting claims to Medicare.

Cover Your Bases When Submitting Claims

Not so fast. It might seem that you can simply submit claims using O&P notes as part of the medical record to prove medical necessity, but when it comes to DME documentation requirements it will pay to use a little extra caution—and a bit more paperwork to support your claims.

Here are a few tips to follow when submitting DME claims to Medicare:

  • Clarify the new guidelines with everyone in your practice so you’re all aware of the rules and how to implement them.
  • Remember that Section 50402 does not mean that O&P notes replace physician notes; they just complement them. If, for example, O&P notes indicate knee instability, but the physician’s notes make no indication that the patient’s symptoms indicate a likelihood of knee instability, your claim won’t pass inspection. At the end of the day, O&P notes help strengthen a claim, but whatever the physician documented takes precedence over any other notes.
  • Consider submitting a copy of Section 50402 when you submit a DME claim that includes copies of your notes proving medical necessity.
  • Have an appeals plan in place should any claims be rejected. Although this shouldn’t happen if physician and O&P notes agree, it’s best to still always be prepared as confusion can ensue when rules are changed.

In the end, DME documentation guidelines can be tricky, especially when the rules change, but being proactive and having your team all on the same page can go a long way in terms of Medicare compliance.

Keep a Sharp Eye on DME Documentation Requirements

As you know, when it comes to CMS documentation guidelines, if you just skip over a word or two, you could get a completely different idea of what Medicare will see when reviewing your claim. Take one more worry off of your shoulders by reviewing the DME documentation requirements step by step in the AudioSolutionz webinar, “CMS 2019 Documentation Guidelines Update for DME.”  Your reimbursement levels and your practice will thank you for it!

To join the conference or see a replay, order a DVD or transcript, or read more

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